Belvedere Nursing and Rehabilitation Center, LLC

Inspectors wroteBased on observations, interview, record review, and facility policy review, it was determined the facility failed to have adequate interventions in the resident's care plan, for non-compliant behaviors, with a resident with a history of nicotine dependence (Resident #9) out of 4 residents reviewed for accidents and adequate individualized care plans. Based on observations, interview, record review, and facility policy review, it was determined that the facility failed to develop and implement a comprehensive care plan for one (Resident #9) out of four residents reviewed. Specifically, to ensure the resident's care plan addressed non-compliant behaviors related to a history of nicotine dependence and bringing electronic cigarettes (vapes) into the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff followed care planned interventions requiring one staff member to perform transfers with gait belt to promote resident safety and prevent injury for 1 (Resident #2) of 3 sampled residents who required one-person transfers with a gait belt. This failed practice resulted in actual harm for Resident #2, who was transferred without the use of a gait belt and sustained a dislocation of the shoulder, proximal humerus fracture, ligamentous injury, and clavicle injury.

Inspectors wroteBased on observation, record review, interview, and facility record review, the facility failed to ensure the central bath and soiled utility room on 300 Hall were locked to prevent resident access to dirty linens, chemicals, and wet floors to prevent accidents and injuries. The facility failed to ensure the mechanical lift was in good working order to prevent accidents and injuries to 1 (Resident #49) of 1 sampled resident reviewed for accidents and injuries.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items when contaminated; 1 of 1 ice machines was maintained in a clean and sanitary condition, and cold dairy products were maintained at 41 degrees Fahrenheit or below for one meal observed.

Inspectors wroteBased on observation and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #11) of 1 resident residing in the Memory Unit, related to identification of the medications the resident was receiving related to the Resident's medical needs.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined that the facility failed to ensure proper hand hygiene was performed during peri care to reduce the risk of cross contamination, and the spread of infection for 1 sampled (Resident #55) resident reviewed for bowel and bladder.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement interventions for previous falls as indicated from the care plan to decrease the potential for future falls with injuries which resulted in a fall with a fracture for 1 (Resident #53); This failed practices had the potential to affect 23 residents who were at risk for falls according to a list provided by the Assistant Director of Nursing on 12/21/23 at 10:39AM. The facility failed to ensure residents who were at risk for fluid aspiration had the correct thickened consistency per physician's orders for 2 of 2 (#85 and #89).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure catheter output bags were concealed in a privacy bag to protect the resident's dignity for 2 (Resident's #39, and #62) of 3 sampled residents who had an indwelling catheter on 300 hall.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident's care plan was individualized to address the residents hearing loss to ensure appropriate care was received for one Resident (#41) of one sampled resident with hearing loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's individualized care plan were updated to ensure appropriate care was received for two Residents (R #33 and R#99) of 2 sampled residents. This failed practice had the potential to affect all 119 residents who reside in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician's order was in the electronic health record prior to administration of oxygen for 1 Resident (d#44) of 5 sampled residents; the facility failed to ensure oxygen tubing and nebulizer mouthpieces were stored in a sanitary manner to prevent the spread of bacteria for 2 Residents (#44 and #270) of 8 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were not left in a resident's room for one Resident (R#97) of one sampled resident.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with updating care plans and initiating a care area on the care plan. These failed practices had the potential to affect all 119 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to store the ice scoop in a closed container to ensure the infection prevention and control program was followed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infection.

Inspectors wroteBased on record review and interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) after a decline in two or more Activities of daily living (ADL) for 1 (Resident #53) of 1 sampled resident whose MDSs were reviewed. This failed practice had the potential to affect all 119 residents in the facility.

Inspectors wroteBased on record review and interview, the facility failed to complete a comprehensive assessment using the Resident Assessment Instrument (RAI) process within regulatory time frames for 2 (Resident #70, and #277) of 2 sampled residents whose MDS were reviewed.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a water management program to prevent the likelihood of waterborne illnesses caused by opportunistic pathogens such as Legionella. This failed practice had the potential to affect all 114 residents in the facility based on the Midnight Census Report which was provided by the Administrator on 10/4/23 at 10:15 a.m.